Mechanical Ventilation in Children

Dr. Tanuj aggarwal

Introduction
Indications Basic anatomy and physiology Modes of ventilation Selection of mode and settings Common problems Complications Weaning and extubation
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Indications
Respiratory Failure
Apnea / Respiratory Arrest inadequate ventilation (acute vs. chronic) inadequate oxygenation chronic respiratory insufficiency with FTT
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Indications
Cardiac Insufficiency
eliminate work of breathing reduce oxygen consumption

Neurologic dysfunction
central hypoventilation/ frequent apnea patient comatose, GCS < 8 inability to protect airway
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Basic Anatomy
Upper Airway
humidifies inhaled gases site of most resistance to airflow

Lower Airway
conducting airways (anatomic dead space) respiratory bronchioles and alveoli (gas exchange)
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Basic Physiology
Negative pressure circuit
Gradient between mouth and pleural space is the driving pressure need to overcome resistance maintain alveolus open overcome elastic recoil forces Balance between elastic recoil of chest wall and the lung
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Basic Physiology

http://www.biology.eku.edu/RITCHISO/301notes6.htm

Normal pressure-volume relationship in the lung

http://physioweb.med.uvm.edu/pulmonary_physiology

Ventilation
Carbon Dioxide
PaCO2= k * metabolic production alveolar minute ventilation

Alveolar MV = resp. rate * effective tidal vol. Effective TV = TV - dead space Dead Space = anatomic + physiologic

Oxygenation
Oxygen:
Minute ventilation is the amount of fresh gas delivered to the alveolus Partial pressure of oxygen in alveolus (PAO2) is the driving pressure for gas exchange across the alveolar-capillary barrier PAO2 = ({Atmospheric pressure - water vapor}*FiO2) - PaCO2 / RQ Match perfusion to alveoli that are well ventilated Hemoglobin is fully saturated 1/3 of the way thru the capillary

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Oxygenation

http://www.biology.eku.edu/RITCHISO/301notes6.htm

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CO2 vs. Oxygen

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Abnormal Gas Exchange

Hypoxemia can be due to: hypoventilation V/Q mismatch shunt diffusion impairments Hypercarbia can be due to: hypoventilation V/Q mismatch

Due to differences between oxygen and CO2 in their solubility and respective disassociation curves, shunt and diffusion impairments do not result in 13 hypercarbia

Definition
Acute respiratory failure- absent respiratory activity or inadequate to maintain oxygen uptake & carbon diaoxide clearance Respiratory insufficiency-if gas exchange is maintained at increased expense of breathing mechanism. Resp failure- PaO2 <60mm PaCO2 >50mm & rising pH<7.25 or less Pao2/FiO2 <150 A-a gradient >350

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Goals of MV
Provide adequate alveolar ventilation (no resp acidosis/alkalosis) Maximise ventilation perfusion relationship for optimal gas exchange Decreased WOB, increased patient comfort Min CVS compromise Normal ABG Increasing oxygenation
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Initial evaluation
Level of consciousness Skin color & appearance RR, HR, BP, temp Tachypnea & tachycardia-early indicators of hypoxia & decrease by 10 by oxygen means hypoxia

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Categories of respiratory failure

CNS- resp centre depression, drugs, brain stem lesions-hhypoventilation or hypercapnic respiratory failure Neuromuscular-LGBS, tetanus, polio Increased work of breathing-1-4% total O2 consumption, increased rate, or depth increases by 35-40%.-pleural effusion, increased resistence or decreased compliance
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Terms used in MV
Respiration-movement of gases across a membrane-external & internal Ventilation-drawing in of gases Pressure difference between mouth & alveoli drives air-end exp-5cm, end insp 10 cm so transpulmonary pressure Compliance-relative ease with which a structure distends or change in volume to presure-V/P Resistance-P/Flow PIP highest pressure at end of inspiration

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 Pressure, time, flow, volume Volume delivered=amount of flow, in time dependent on difference in pressure Time constant-rate at which indvidual unit fills=compliancexresistance

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Gas Exchange
Hypoventilation and V/Q mismatch are the most common causes of abnormal gas exchange in the PICU Can correct hypoventilation by increasing minute ventilation Can correct V/Q mismatch by increasing amount of lung that is ventilated or by improving perfusion to those areas that are ventilated
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Mechanical Ventilation
What we can manipulate
Minute Ventilation (increase respiratory rate,
tidal volume)

Pressure Gradient = A-a equation (increase atmospheric pressure, FiO2,

increase ventilation, change RQ)

Surface Area = volume of lungs available for ventilation (increase volume by

increasing airway pressure, i.e., mean airway pressure)

Solubility = ?perflurocarbons?

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Mechanical Ventilation
Ventilators deliver gas to the lungs using positive pressure at a certain rate. The amount of gas delivered can be limited by time, pressure or volume. The duration can be cycled by time, pressure or flow.
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Nomenclature
Airway Pressures
Peak Inspiratory Pressure (PIP) Positive End Expiratory Pressure (PEEP) Pressure above PEEP (PAP or P) Mean airway pressure (MAP) Continuous Positive Airway Pressure (CPAP)

Inspiratory Time or I:E ratio Tidal Volume: amount of gas delivered with each breath
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Modes
Control Modes:
every breath is fully supported by the ventilator in classic control modes, patients were unable to breathe except at the controlled set rate in newer control modes, machines may act in assist-control, with a minimum set rate and all triggered breaths above that rate also fully supported.

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Modes
IMV Modes: intermittent mandatory ventilation modes - breaths above set rate not supported SIMV: vent synchronizes IMV breath with patients effort Pressure Support: vent supplies pressure support but no set rate; pressure support can be fixed or variable
(volume support, volume assured support, etc)
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Modes
Whenever a breath is supported by the ventilator, regardless of the mode, the limit of the support is determined by a preset pressure OR volume.
Volume Limited: preset tidal volume

Pressure Limited: preset PIP or PAP

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Mechanical Ventilation
If volume is set, pressure varies..if pressure is set, volume varies.. .according to the compliance...
COMPLIANCE = Volume / Pressure
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Compliance

Burton SL & Hubmayr RD: Determinants of Patient-Ventilator Interactions: Bedside Waveform Analysis, in Tobin MJ (ed): Principles & Practice of 28 Intensive Care Monitoring

Assist-control, volume

Ingento EP & Drazen J: Mechanical Ventilators, in Hall JB, 29 Scmidt GA, & Wood LDH(eds.): Principles of Critical Care

IMV, volume-limited

Ingento EP & Drazen J: Mechanical Ventilators, in Hall JB, 30 Scmidt GA, & Wood LDH(eds.): Principles of Critical Care

SIMV, volume-limited

Ingento EP & Drazen J: Mechanical Ventilators, in Hall JB, Scmidt GA, & Wood LDH(eds.): Principles of Critical 31 Care

Control vs. SIMV

Control Modes
Every breath is supported regardless of trigger Cant wean by decreasing rate Patient may hyperventilate if agitated Patient / vent asynchrony possible and may need sedation +/- paralysis

SIMV Modes
Vent tries to synchronize with pts effort

Patient takes own breaths in between (+/PS)

Potential increased work of breathing Can have patient / vent asynchrony 32

Pressure vs. Volume

Pressure Limited
Control FiO2 and MAP (oxygenation) Still can influence ventilation somewhat
(respiratory rate, PAP)

Volume Limited
Control minute ventilation Still can influence oxygenation somewhat (FiO2, PEEP, I-time) Square wave flow pattern
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Decelerating flow pattern (lower PIP for

same TV)

Pressure vs. Volume

Pressure Pitfalls
tidal volume by change suddenly as patients compliance changes this can lead to hypoventilation or overexpansion of the lung if ETT is obstructed acutely, delivered tidal volume will decrease

Volume Vitriol
no limit per se on PIP (usually vent will have upper pressure limit) square wave(constant) flow pattern results in higher PIP for same tidal volume as compared to Pressure modes
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Trigger
How does the vent know when to give a breath? - Trigger patient effort elapsed time
The patients effort can be sensed as a change in pressure or a change in flow (in the circuit)
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Need a hand??
Pressure Support Triggering vent requires certain amount
of work by patient Can decrease work of breathing by providing flow during inspiration for patient triggered breaths Can be given with spontaneous breaths in IMV modes or as stand alone mode without set rate Flow-cycled 36

Advanced Modes
Pressure-regulated volume control (PRVC) Volume support Inverse ratio (IRV) or airway-pressure release ventilation (APRV) Bilevel High-frequency
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Advanced Modes
PRVC
A control mode, which delivers a set tidal volume with each breath at the lowest possible peak pressure. Delivers the breath with a decelerating flow pattern that is thought to be less injurious to the lung the guided hand.
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Advanced Modes
Volume Support
equivalent to smart pressure support set a goal tidal volume the machine watches the delivered volumes and adjusts the pressure support to meet desired goal within limits set by you.
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Advanced Modes
Airway Pressure Release Ventilation
Can be thought of as giving a patient two different levels of CPAP Set high and low pressures with release time Length of time at high pressure generally greater than length of time at low pressure By releasing to lower pressure, allow lung volume to decrease to FRC

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Advanced Modes
Inverse Ratio Ventilation
Pressure Control Mode I:E > 1 Can increase MAP without increasing PIP: improve oxygenation but limit barotrauma Significant risk for air trapping Patient will need to be deeply sedated and perhaps paralyzed as well
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Advanced Modes
High Frequency Oscillatory Ventilation
extremely high rates (Hz = 60/min) tidal volumes < anatomic dead space set & titrate Mean Airway Pressure amplitude equivalent to tidal volume mechanism of gas exchange unclear traditionally rescue therapy active expiration
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Advanced Modes
High Frequency Oscillatory Ventilation
patient must be paralyzed cannot suction frequently as disconnecting the patient from the oscillator can result in volume loss in the lung likewise, patient cannot be turned frequently so decubiti can be an issue turn and suction patient 1-2x/day if they can tolerate it
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Advanced Modes
Non Invasive Positive Pressure Ventilation
Deliver PS and CPAP via tight fitting mask (BiPAP: bi-level positive airway pressure) Can set back up rate May still need sedation

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Initial Settings
Pressure Limited Volume Limited
FiO2 Rate I-time or I:E ratio PEEP PIP or PAP FiO2 Rate I-time or I:E ratio PEEP Tidal Volume

These choices are with time - cycled ventilators. Flow cycled vents are available but not commonly used in pediatrics. 45

Initial Settings
Settings
Rate: start with a rate that is somewhat normal; i.e., 15 for adolescent/child, 20-30 for infant/small child FiO2: 100% and wean down PEEP: 3-5 Control every breath (A/C) or some (SIMV) Mode ?
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Dealers Choice
Pressure Limited Volume Limited
FiO2 Rate I-time PEEP PIP MAP FiO2 Rate Tidal Volume MV PEEP I time

Tidal Volume ( & MV) Varies

PIP ( & MAP) Varies

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Adjustments
To affect oxygenation, adjust: FiO2 PEEP I time PIP

To affect ventilation, adjust:

Respiratory Rate MV

MAP

Tidal Volume
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Adjustments
PEEP
Can be used to help prevent alveolar collapse at end inspiration; it can also be used to recruit collapsed lung spaces or to stent open floppy airways

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Except...
Is it really that simple ?
Increasing PEEP can increase dead space, decrease cardiac output, increase V/Q mismatch Increasing the respiratory rate can lead to dynamic hyperinflation (aka auto-PEEP), resulting in worsening oxygenation and ventilation
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Ventilator strategies
3 categories -normal lungs -restrictive lung disease -obstructive lung disease Normal lungs-Initially full ventilatory support (FVS)-secure airways, ventilation, hypercapnia, low pressure, easy to wean

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Ventilator strategies
Restrictive lungs-loss of FRC, hypoxemia PEEP, initially FVS with sedation(m. realxants) High PIP Obstructive lungs Gas trapping, slow rates, permissive hypercapnia

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Volume cycled
PaO2 normal 80-100mm Hg Mild hypoxia 60-80 Moderate hypoxia 40-60 Severe hypoxia <40 mm Hg Rate-physiological <1 yr-30/min,1-5yr 25-30, 5-10 yr 20, >10 yrs 15/min

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Initial settings
Ti 0.4 to 0.75 sec, maintaining I;:E ratio 1:2 Flow l/kg/min (tidal volume/inspiratory time) P-support- min 10 cm PEEP- normal 3-4 cm Alarms High P 30 cm Low P 10 cm Low PEEP 3cm

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Initial Settings
Parameter
Tidal volume Rate FiO2 PEEP PIP ABG Pao2 PaCO2

Normal lungs
12-15 ml/kg On higher side To keep PaO2>80mm 3-5 cm Keep <35 cm 80-100 35-40

Restrictive lung
6-10ml/kg Normal acc to age PaO2 50-80mm 5-8 cm <35 cm 50-80 Allow it to rise>60 if necessary

Obstructive lung
8-12ml/kg Less than normal PaO2>60mm 2-3 cm <35 cm Allow to rise >60mm if necessary
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Troubleshooting
Is it working ?

Look at the patient !! Listen to the patient !!

Pulse Ox, ABG, EtCO2 Chest X ray Look at the vent (PIP; expired TV; alarms)
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Improving ventilation
Minute ventilation=tidal volume x RR To decrease PaCO2-increase tidal volume if RR already physiological In hypocapnia decrease RR first Desired PaCO2=kPaCO2xkVT or RR/desired PaCO2(40mm)

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Improving oxygenation
Increase Mean airways pressure (MAP) PIP/VT,PEEP,Flow,Ti FiO2 (dFiO2=kFiO2/kPO2 x d PO2 Least toxic FiO2 safe till 60%(initially upto 100%) Then PEEP(as FiO2), Ti (as PIP/VT already set to keep PIP<35 cm). Normal MAP 5-10cm, can increase upto 1015 cm, barotrauma more if >15 cm.
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Troubleshooting
When in doubt, DISCONNECT THE PATIENT FROM THE VENT, and begin bag ventilation. Ensure you are bagging with 100% O2. This eliminates the vent circuit as the source of the problem. Bagging by hand can also help you gauge patients compliance
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Troubleshooting
Airway first: is the tube still in? (may need
DL/EtCO2 to confirm) Is it patent? Is it in the right position? Breathing next: is the chest rising? Breath sounds present and equal? Changes in exam? Atelectasis, bronchospasm, pneumothorax, pneumonia? (Consider needle thoracentesis) Circulation: shock? Sepsis?

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Troubleshooting
Well, it isnt working..
Right settings ? Right Mode ? Does the vent need to do more work ?
Patient unable to do so Underlying process worsening (or new problem?)

Air leaks? Does the patient need to be more sedated ? Does the patient need to be extubated ? Vent is only human..(is it working ?)
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Troubleshooting
Patient - Ventilator Interaction
Vent must recognize patients respiratory efforts (trigger)

Vent must be able to meet patients demands (response)

Vent must not interfere with patients efforts (synchrony)
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Troubleshooting
Improving Ventilation and/or Oxygenation
can increase respiratory rate (or decrease rate if air trapping is an issue) can increase tidal volume/PAP to increase tidal volume can increase PEEP to help recruit collapsed areas can increase pressure support and/or decrease sedation to improve patients spontaneous effort
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Lowered Expectations
Permissive Hypercapnia
accept higher PaCO2s in exchange for limiting peak airway pressures can titrate pH as desired with sodium bicarbonate or other buffer

Permissive Hypoxemia
accept PaO2 of 55-65; SaO2 88-90% in exchange for limiting FiO2 (<.60) and PEEP can maintain oxygen content by keeping hematocrit > 30%
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Adjunctive Therapies
Proning
re-expand collapsed dorsal areas of the lung chest wall has more favorable compliance curve in prone position heart moves away from the lungs net result is usually improved oxygenation care of patient (suctioning, lines, decubiti) trickier but not impossible not everyone maintains their response or even responds in the first place
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Adjunctive Therapies
Inhaled Nitric Oxide
vasodilator with very short half life that can be delivered via ETT vasodilate blood vessels that supply ventilated alveoli and thus improve V/Q no systemic effects due to rapid inactivation by binding to hemoglobin improves oxygenation but does not improve outcome
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Complications
Ventilator Induced Lung Injury
Oxygen toxicity Barotrauma / Volutrauma Peak Pressure Plateau Pressure Shear Injury (tidal volume) PEEP
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Complications
Cardiovascular Complications
Impaired venous return to RH Bowing of the Interventricular Septum Decreased left sided afterload (good) Altered right sided afterload

Sum Effect..decreased cardiac output

(usually, not always and often we dont even notice)

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Complications
Other Complications
Ventilator Associated Pneumonia Sinusitis Sedation Risks from associated devices (CVLs, A-lines) Unplanned Extubation
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Extubation
Weaning
Is the cause of respiratory failure gone or getting better ? Is the patient well oxygenated and ventilated ? Can the heart tolerate the increased work of breathing ?
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Extubation
Weaning (cont.)
decrease the PEEP (4-5) decrease the rate decrease the PIP (as needed)

What you want to do is decrease what the vent does and see if the patient can make up the difference.
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Weaning
Gradually change repsiratory rate, watch for changes in HR,RR, or BP, if change of >20% stop weaning. Infants decrease RR to 10, then put on T-tube, in older children decrease to 68 breaths.

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Extubation
Extubation
Control of airway reflexes Patent upper airway (air leak around tube?)

Minimal oxygen requirement

Minimal rate Minimize pressure support (0-10)

Awake patient

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